Hywel Dda University Health Board

Mrs A complained about care and treatment provided to her son, B, by Hywel Dda University Health Board. The investigation considered the concern that B’s prescription of isotretinoin (a medicine used to treat severe acne) was not managed appropriately between September 2022 and January 2023.

The Ombudsman found that the decision to increase B’s dosage of isotretinoin following a nurse-led virtual appointment on 8 November 2022 was not appropriate as there was evidence that his acne had progressively worsened. At the same appointment there was a failure to identify the need for B to be seen urgently face-to-face. The Ombudsman found, on a balance of probabilities, that earlier review and treatment could have limited the deterioration of B’s acne and associated scarring. Mrs A’s complaint was therefore upheld.

The Health Board agreed to the Ombudsman’s recommendations, including to apologise to Mrs A and B and make a payment of £1000 to B to reflect the missed opportunity to limit the extent of skin damage he developed. It also agreed to arrange for the Ombudsman’s report to be shared with the clinical director responsible for the dermatology service and discussed at a relevant clinical governance meeting.